Introduction: Patient identification is a significant area in every medical field. Misidentification of patients leads to various challenges, such as surgical operation on the wrong patient, erroneous prescription of medications, and mistakes in performing the treatment procedures. Therefore, patient misidentification is associated with significant malpractice and economic loss. Healthcare providers and staff members are responsible for the management of the patients’ information and their proper identification.Case: We presented a typical case of misidentification, which might have led to performing a surgical procedure on a misidentified patient. In this report, we have discussed the outlines of the misidentified case, contributing factors leading to the incident, and provided recommendations on the potential solutions that could be considered to avoid similar incidents and enhance patient safety. In addition, the presented case has been compared with the World Health Organization (WHO) protocols and guidelines on the prevention of patient misidentification and proper communication within the medical team.Conclusion: Adopting a technologically advanced system and proper training of healthcare providers are essential to improving patient safety and diminishing legal challenges in the field of medicine.